NVR300000 - Nevada
Nevada Division of Environmental Protection
Bureau of Water Pollution Control
ANNUAL REPORT
For NPDES General Permit NVR050000 (MSGP)
Authorization to Discharge Storm Water Associated with Industrial Activity
Instructions: Complete the following annual report using the records compiled for NPDES General Permit NVR050000 (MSGP), effective on June 10, 2019. All facilities shall complete this Annual Report in accordance with the schedule provided in Section 8.2 of the MSGP. Except as required by Section 7.2.4, Annual Reports are not required to be submitted to the Division; however, the Annual Report shall be retained onsite with the SWPPP.
Reporting Year:[pic] County where facility is located: [pic]
Primary SIC Code: [pic] Sector(s): [pic] Sub-sector(s): [pic]
1. Facility Name: Site ID: ISW-[pic]
Facility Address:
Facility City: [pic] ZIP Code: [pic]
2. Stormwater Pollution Prevention Team Leader
Name: [pic] Title: [pic]
Phone: [pic] Email: [pic]
3. Does the facility have a current Stormwater Water Pollution Prevention Plan (SWPPP) that includes all elements required by the MSGP? YES NO
4. Are all elements of the SWPPP presently in place, in good repair and functioning properly, including all BMPs and any spill response equipment? YES NO
5. Were the quarterly Routine Facility Inspections conducted? If any were missed attach a narrative description of why. YES NO
Dates:
6. Were the quarterly Stormwater Visual Assessments conducted? If any were missed attach a narrative description of why. YES NO
Dates:
7. Based on inspection results was the SWPPP adequate to meet applicable MSGP requirements?
YES NO
8. If SWPPP revisions were necessary, have they been implemented at the facility? YES NO
If no, why?
9. Did the facility inspect for the presence of non-storm water discharges and document findings in the SWPPP? YES NO
If no, why?
10. Has the facility documented corrective actions (required by Section 5.0 of the permit) in the SWPPP? Have they been completed, if not why and give an estimated date of completion (attach to report).
YES NO
11. Describe any BMP additions or modifications planned, and those completed during the prior year (attach additional sheets if necessary)
Planned:
Completed:
12. Has the facility reviewed the Division’s most current 303(d) list for impaired waters and the approved TMDLs and complied with Sections 7.4 and 7.5 of this permit as applicable? If no, describe why.
YES NO
13. Is the facility required to conduct monitoring in compliance with Section 7.2 and 7.5 of the MSGP?
YES NO
If yes, attach a one page summary of the sampling results, to this report along with the laboratory report.
14. Provide any additional comments and/or explanations of any of the above answers (use a separate sheet if needed):
CERTIFICATION STATEMENT
“I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.”
Print name and title: __________________________________________________________________
Signature:_________________________________________________Date:_____________________
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